The 60% Rule: Essential Knowledge for Liaisons
This comprehensive guide will help you understand the 60% Rule, its importance for Medicare compliance, and how to properly document patients who fall under this rule. Mastering these concepts is critical for ensuring proper patient care and withstanding Medicare audits.
Pre-Screen Documentation: The Foundation
Why Pre-Screen Documentation Matters
Pre-screen documentation is a foundational process for inpatient rehabilitation facilities (IRFs) to ensure patients meet the criteria for admission and that the IRF remains compliant with Medicare regulations. Medicare auditors meticulously review pre-screen documentation to validate medical necessity, appropriate utilization of services, and compliance with the 60% and 40% rules.
Why Medicare Audits Pre-Screen Documentation
Medicare audits pre-screen documentation for the following reasons:
- Compliance with Regulations: To ensure IRFs admit patients who meet CMS criteria
- Medical Necessity: To validate that the patient requires intensive rehabilitation and an interdisciplinary approach
- Prevent Fraud and Abuse: To ensure IRFs are not admitting patients who could safely receive care in a lower level of care
Key Areas Auditors Focus On:
- Medical Necessity: Is there a documented need for intensive rehabilitation?
- Interdisciplinary Care Requirements: Does the patient require the coordinated efforts of at least two therapy disciplines?
- Prior Level of Functioning and Current Deficits: Is the patient's functional status clearly documented, showing a significant need for rehabilitation?
- Reasonable and Necessary Goals: Are the rehabilitation goals realistic, individualized, and achievable within a reasonable timeframe?
- Physician Involvement: Is there evidence of active physician oversight and certification?
Consequences of Poor Documentation
Inadequate pre-screen documentation can have significant consequences, including:
- Claim Denials: Medicare may refuse to pay for services if documentation does not support medical necessity
- Repayment Demands: IRFs may be required to return funds for services that do not meet Medicare criteria
- Penalties: Repeated non-compliance can lead to fines, sanctions, or exclusion from Medicare programs
- Damage to Reputation: Non-compliance can tarnish the IRF's reputation, impacting referrals and patient trust
What is the 60% Rule?
The 60% Rule is a Medicare requirement that mandates at least 60% of an IRF's total patient population must have one of a specific set of qualifying conditions that require intensive rehabilitation. These conditions are considered medically complex and justify the need for inpatient rehabilitation services, as opposed to care in a lower-level setting (e.g., SNF or home health).
The remaining 40% of patients may have other conditions that require IRF services but don't fall under the qualifying diagnoses list.
Qualifying Diagnoses Under the 60% Rule
The following are the 13 qualifying conditions under the 60% Rule, as defined by Medicare:
Why the 60% Rule Matters
Compliance and Medicare Audits:
- Medicare auditors closely evaluate whether patients with qualifying diagnoses meet the criteria for intensive rehabilitation
- Failure to meet the 60% threshold can result in penalties and repayment demands for improperly documented cases
Documentation Standards:
- Accurate documentation must clearly tie the qualifying diagnosis to the patient's rehabilitation needs
- Evidence of functional deficits, medical necessity, and interdisciplinary care must be included
Elements of Comprehensive Pre-Screen Documentation
To ensure compliance, pre-screen documentation must include the following elements:
1. Patient Background Information
- Patient demographics (name, date of birth, etc.)
- Primary diagnosis and comorbid conditions
- History of present illness and reason for referral
2. Prior Level of Functioning (PLOF)
A detailed description of the patient's functional status before the onset of the condition or injury.
Example: "Patient was independent with all ADLs (activities of daily living), ambulated without assistance, and managed household tasks without difficulty."
3. Current Functional Deficits
A clear description of the patient's current impairments, including mobility, ADLs, and cognitive/communication deficits.
Example: "Patient requires max assist for transfers, is non-ambulatory, and demonstrates moderate cognitive impairments impacting safety awareness."
4. Medical Necessity for Intensive Rehabilitation
Justification for why the patient requires an IRF level of care, rather than a lower level of care (e.g., SNF or home health).
Example: "Patient requires a minimum of three hours of intensive therapy per day from physical and occupational therapy, along with speech therapy to address cognitive deficits."
5. Rehabilitation Goals
Specific, measurable, and realistic goals for the patient.
Example: "Patient will progress from max assist to min assist for transfers and ambulation within 10 days."
6. Interdisciplinary Care Requirements
Evidence that the patient requires coordinated care from two or more therapy disciplines (e.g., physical therapy, occupational therapy, speech therapy).
7. Physician Involvement
Documentation of the referring physician's certification of medical necessity and commitment to active oversight during the patient's stay.
Best Practices for Documenting 60% Rule Patients
To ensure compliance, follow these battle-tested practices for documenting patients who fall under the 60% Rule:
1. Clearly State the Qualifying Diagnosis
Include the primary qualifying diagnosis in the pre-screen documentation.
Example: "Patient admitted for intensive rehabilitation following a left middle cerebral artery ischemic stroke."
2. Detail Functional Deficits
Document how the qualifying condition affects mobility, ADLs, and cognitive or communication abilities.
Example: "Patient presents with right-sided hemiparesis, requiring max assist for transfers, dependent for dressing and bathing, and demonstrating expressive aphasia."
3. Justify Medical Necessity for IRF Care
Explain why the patient requires intensive rehabilitation rather than a lower level of care.
Example: "Patient requires a minimum of three hours of therapy per day from PT, OT, and SLP to address mobility deficits, ADL retraining, and aphasia. Patient also requires close medical supervision for hypertension and diabetes, which may impact therapy progress."
4. Highlight Interdisciplinary Care
Show the need for at least two therapy disciplines working together to address the patient's complex needs.
Example: "PT will focus on improving strength and balance for ambulation, OT will address ADL retraining, and SLP will work on expressive language deficits."
5. Include Measurable Goals
Ensure goals are specific, realistic, and time-bound.
Example: "Within 10 days, patient will progress to mod assist for transfers and ambulate 50 feet with a walker and supervision. Within 14 days, patient will independently perform grooming tasks with setup assistance."
Pre-Screen Documentation Checklist
Use this checklist to ensure your pre-screen documentation is complete and compliant:
Patient Information
Functional Status
Medical Necessity
Rehabilitation Plan
Case Studies: 60% Rule Diagnoses
The following case studies illustrate how to properly document patients with qualifying diagnoses under the 60% Rule:
Case 1: Stroke
- Patient: 72-year-old male with right-sided hemiplegia following an ischemic stroke
- PLOF: Independent with all ADLs and ambulation
- Current Status: Dependent for transfers and ADLs, non-ambulatory, and demonstrating expressive aphasia
- Rehab Goals: Progress to min assist for transfers, ambulate 50 feet with a walker, and improve communication for basic needs
Case 2: Spinal Cord Injury
- Patient: 45-year-old female with T6 complete spinal cord injury following a motor vehicle accident
- PLOF: Independent with all activities
- Current Status: Paraplegia, requiring max assist for transfers and bed mobility
- Rehab Goals: Achieve independence with wheelchair mobility and training in ADLs
Case 3: Brain Injury
- Patient: 36-year-old male with a traumatic brain injury (TBI) after a fall
- PLOF: Independent with all ADLs and working full-time
- Current Status: Mod assist for transfers, impaired safety awareness, and short-term memory deficits
- Rehab Goals: Improve cognitive function and safety awareness, and progress to supervision for transfers
Case 4: Amputation
- Patient: 58-year-old male with a below-knee amputation due to diabetes-related complications
- PLOF: Ambulated independently with no assistive devices
- Current Status: Non-ambulatory, requiring mod assist for transfers and ADLs
- Rehab Goals: Achieve independence with prosthetic training and progress to ambulation with a walker
Case 5: Hip Fracture
- Patient: 80-year-old female with a hip fracture after a fall
- PLOF: Independent with ambulation using a cane
- Current Status: Max assist for transfers and non-ambulatory
- Rehab Goals: Progress to mod assist for ambulation with a walker and achieve independence in ADLs
Case 6: Neurological Disorders (Parkinson's Disease)
- Patient: 70-year-old male with Parkinson's disease and significant mobility decline
- PLOF: Ambulated independently with minimal tremors
- Current Status: Mod assist for ambulation and ADLs, with frequent freezing episodes
- Rehab Goals: Improve gait and balance to progress to supervision for ambulation
Case 7: Burns
- Patient: 30-year-old male with third-degree burns covering 40% of his body after a workplace accident
- PLOF: Fully independent
- Current Status: Dependent for ADLs due to pain and limited range of motion
- Rehab Goals: Regain functional mobility, improve ROM, and progress toward independence in ADLs
Case 8: Polyarticular Rheumatoid Arthritis
- Patient: 65-year-old female with severe rheumatoid arthritis affecting bilateral knees and hips
- PLOF: Independent in ADLs with mild pain
- Current Status: Mod assist for transfers and ADLs due to pain and stiffness
- Rehab Goals: Reduce pain and stiffness, improve mobility, and achieve independence in ADLs
Examples of Good vs. Poor Documentation
The following examples illustrate the difference between poor and good documentation for patients under the 60% Rule:
Example 1: Stroke Patient
Poor Documentation:
"Patient had a stroke and needs therapy to improve function."
Why It's Inadequate:
- No details about the type of stroke or affected areas
- No description of functional deficits
- No justification for IRF-level care
- No mention of prior level of functioning
- No specific rehabilitation goals
Good Documentation:
"Patient is a 72-year-old male who experienced a left middle cerebral artery ischemic stroke 5 days ago, resulting in right-sided hemiplegia and expressive aphasia.
PLOF: Prior to stroke, patient was independent with all ADLs and ambulation without assistive devices. He lived alone in a single-story home and was active in his community.
Current Functional Status: Patient presents with dense right hemiplegia (0/5 strength in right UE and LE), requiring max assist for bed mobility and transfers. Patient is non-ambulatory and dependent for all ADLs. Patient demonstrates moderate expressive aphasia with good comprehension but limited verbal output.
Medical Necessity: Patient requires intensive rehabilitation with at least 3 hours of therapy daily from multiple disciplines to address significant functional deficits. Close physician oversight is needed to monitor neurological status and manage hypertension and diabetes, which may impact recovery. Patient's complex needs cannot be safely addressed in a lower level of care.
Interdisciplinary Approach: PT will address transfers, mobility, and balance; OT will focus on ADL retraining and upper extremity function; and SLP will address communication deficits and swallowing safety.
Rehabilitation Goals: Within 7 days, patient will progress to mod assist for transfers. Within 14 days, patient will ambulate 50 feet with a hemiwalker and min assist, and will perform basic grooming tasks with setup assistance. Patient will communicate basic needs using simple phrases or alternative communication methods."
Example 2: Hip Fracture Patient
Poor Documentation:
"Patient fell and broke hip. Needs rehab after surgery."
Why It's Inadequate:
- No details about the fracture type or surgical intervention
- No description of current functional limitations
- No information about prior level of functioning
- No justification for IRF-level care versus SNF
- No rehabilitation goals or plan
Good Documentation:
"Patient is an 80-year-old female who sustained a right intertrochanteric femur fracture after a fall at home 3 days ago. Patient underwent ORIF on 9/15/2023.
PLOF: Prior to fracture, patient was independent with ambulation using a straight cane due to mild osteoarthritis. She was independent with all ADLs and lived alone in a two-story home with bedroom and bathroom on the second floor.
Current Functional Status: Patient is non-weight bearing on right LE per surgical precautions. Requires max assist for bed mobility and transfers. Unable to ambulate. Requires mod assist for upper body dressing and max assist for lower body dressing and bathing. Patient demonstrates decreased endurance with therapy sessions, requiring frequent rest breaks.
Medical Necessity: Patient requires intensive rehabilitation with at least 3 hours of therapy daily to address significant functional deficits and prepare for return home. Patient has multiple comorbidities including hypertension, osteoporosis, and diabetes that require close medical monitoring during rehabilitation. Patient's complex needs and non-weight bearing status require IRF-level care rather than SNF.
Interdisciplinary Approach: PT will address transfers, mobility training with appropriate assistive devices, and strengthening; OT will focus on ADL retraining and energy conservation techniques.
Rehabilitation Goals: Within 7 days, patient will perform transfers with mod assist. Within 14 days, patient will ambulate 50 feet with a walker and supervision (when weight-bearing status changes), and will perform basic ADLs with min assist. Long-term goal is to return home with appropriate home modifications and support services."
Key Takeaways for the 60% Rule
- The 60% Rule applies to patients with qualifying diagnoses that require intensive rehabilitation.
- Documentation must clearly describe functional deficits, medical necessity, and interdisciplinary care needs.
- Use specific, measurable goals to justify the patient's rehabilitation plan.
- Failure to meet the 60% threshold can result in compliance issues during Medicare audits.
- A thorough pre-screen is essential for identifying appropriate patients and documenting their needs accurately.
- Always include detailed information about prior level of functioning and current deficits.
- Clearly explain why the patient requires IRF-level care rather than a lower level of care.
- Document the need for physician oversight and interdisciplinary care.